Violent & Aggressive Patients Policy

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Bartlemas Surgery is committed to taking all reasonable precautions necessary to ensure the health, safety, welfare and well-being of its employees, patients and visitors, and endeavours to ensure that all employees are protected from physical and verbal abuse while they are working.

The Practice acknowledges that there may be instances where violence and / or aggression forms part of a patient’s illness. In these circumstances, the issue will be discussed with the patient and form part of their care planning.

This information will be recorded in the patient’s medical record and flagged to ensure that staff are aware. In addition, where deemed necessary, appropriate support will be put in place, e.g. staff member does not see the patient alone.

Definition of Physical and Verbal Abuse and Violence:

Physical and verbal abuse includes:

Unreasonable and / or offensive remarks or behaviour / rude gestures / innuendoes
Sexual and racial harassment 3. Threatening behaviour (with or without a weapon)
Actual physical assault (whether or not it results in actual injury) includes being pushed or shoved as well as being hit, punched or attacked with a weapon, or being intentionally struck with bodily fluids or excrement.
Attacks on Partners, members of staff or the public
Discrimination of any kind
Damage to employee's or employer's property

The Practice supports the NHS policy of Zero Tolerance which defines violence as:

"Any incident where staff are abused, threatened or assaulted in circumstances related to their work, involving an explicit or implicit challenge to their safety, well-being or health".

Violence and aggression towards a person may also be defined as:

"A physical contact with another person which may or may not result in pain or injury. The contact is uninvited and is an attempt to cause harm, injury or to intimidate. Non-physical aggression includes the use of language which causes offence or threatens the safety of a member of staff".

Types of difficult / angry patients

Withdrawn, secretive, vague - limits information as a form of control
Critical – everything is wrong, bad
Intimidating – highly sarcastic, cutting
Sad sack - dwell on all the misfortunes, make others feel guilty.

Anger can be a common and normal reaction

Often due to a loss of control, feelings of powerlessness
Can sometimes be justified – e.g. due to late/missed diagnosis, medical errors, fatalities, poor quality care, inadequate pain control, excessive waiting times, rudeness, etc

How you might recognise when someone is angry:

Raised voice/shouting
Flushed face
Wild gesticulations
Angry words
Rigid body
Withdrawal
Sarcasm
Dismissive comments
Gritted teeth, clenched jaw

Policy

This document sets out our policy for dealing with violence and aggression whether it is committed by or against any patient, visitor, or person working in the practice.

This policy applies throughout the Practice premises, including car parks, grounds and any outbuildings.

Practice Responsibilities

The Practice willseek to ensure that it takes all measures to prevent:

Physical or verbal abuse of its employees, including racial and sexual harassment.
Physical assault on employees by patients and other members of staff.

Both management and employees of the Practice have a responsibility for trying to prevent and control physical and verbal abuse by patients and other members of staff.

The Practice will:

Ensure that Doctors, managers and supervisors are responsible for the adequate supervision of employees to ensure that they do not put themselves at risk of physical and verbal abuse by patients.
Ensure that the contents of this document are brought to the attention of employees under their control.
Undertake suitable and sufficient violence and aggression risk assessments, in those areas for which they are responsible to quantify any risks and to identify proactive measures to eliminate and/or control the risks.
Ensure new staff members are made aware of this policy as part of their induction.
Ensure victims of physical assault or serious non-physical assault are offered support through occupational health or the employee assistance programme.
Ensure a culture exists in which all violence and aggression incidents are reported in accordance with the practice’s significant event policy.

Under the Health and Safety at Work Act 1974, the Practice will also undertake the following measures to ensure a safe work environment:

Carry our risk assessments to assess and review the duties of employees, identifying any "at risk" situations and taking appropriate steps to reduce or remove the risk to employees, particularly if they are working alone.
Assess and review the layout of the premises to reduce the risk to employees where physically possible.
Assess and review the provision of personal safety equipment, such as alarms.
Develop surgery policies, procedures and guidelines for dealing with physical and verbal abuse.
Provide support and counselling for victims, or refer to suitably qualified health professionals.
Make employees aware of risks and ensure employee involvement in suitable training courses.
Record any incidents on a Significant Event Form and take any remedial action to ensure similar incidents are prevented in future.

Employee Responsibilities

At all times, employees should take care to ensure a safe work environment and must consider their own safety and that of their colleagues. They must:

Familiarise themselves with this Policy and conform to the requirements, guidelines and instructions contained within it.
Ensure they are familiar with the location of equipment or devices provided for use in at risk situations (e.g. panic buttons / alarms etc.) and know how to use them.
Be responsible for their own security and the security of others who may be affected by their acts and omissions
Co-operate with managers on security matters and observe all safety rules at all times
Undertake and participate in relevant training made available by the Practice
Promptly report all incidents of physical or verbal abuse (threatened or actual), violence and aggression incidents, hazards or near misses and damage, in accordance with the Practice Significant Event Policy
Record all details of incidents in compliance with Practice procedures.  Contribute towards reviews by doctors, the Practice manager or other supervisor concerning any incidents in which they have been involved.
Suggest precautionary measures involving changes in the layout of the work environment that can reduce risk, such as removal of possible weapons or projectiles (e.g. telephones or letter openers) from patient access.
Make use of any staff support and counselling available through the Practice, if required.
Advise the Practice manager or supervisor of any perceived risks involved in work activities.
Never attempt to physically tackle someone during a violent or aggressive incident.

Practice support for employees subjected to abuse

The Practice takes a serious view of any incidents of physical and verbal abuse against its employees and will support them, if assaulted, threatened or harassed, so long as the employee is correctly carrying out his or her duties.

The first concern of the manager after an incident is to provide appropriate debriefing and counselling for affected employees. Depending on the severity of the incident, this counselling may be undertaken by trained professionals.

The Practice Manager or supervisor will assist victims of violence with the completion of the Significant Event Form and where appropriate will report the incident to the police.

In the event of serious physical and or verbal abuse, patients causing this will be removed from the Practice List.

With this in mind, posters are displayed in the waiting room stating the following Practice policy:

Our Practice staff are here to help you.
Our aim is to be as polite and helpful as possible to all patients.
If you consider that you have been treated unfairly or inappropriately, please ask the reception staff to contact the manager or supervisor, who will be happy to address your concerns.
However, shouting and swearing at Practice staff will not be tolerated under any circumstances and patients who are abusive may be removed from the Practice List.
Please help us to help you.

Dealing with violence in the waiting room

The essential points when dealing with violence in the waiting room are to:

Dial 999 to call the police.
Use the emergency panic alarm button.
Work as a team.
Do not put yourself or your colleagues in danger.
Evacuate other patients from the waiting room.

If an incident occurs

Ask the perpetrator to stop behaving in an unacceptable way, remaining calm. Under no circumstances should you respond in the same manner (see Appendix 1) below.
If a member of staff receives an abusive telephone call, they should warn the caller that they will terminate the call if they do not modify their behaviour. If the caller continues to be abusive, the staff member has the authority to terminate the call.
If the perpetrator continues, call your line manager to attend the incident, explaining, in a calm manner, what has occurred. Ideally the perpetrator should also be able to hear what you are saying. 
Should the perpetrator be breaking the law, physically assault anyone or cause damage to the premises, call the police straight away.
Do not attempt to remove the person from the premises unless it is under extreme circumstances. Call the police.
If it is necessary to resort to calling the police and having the person removed, all staff involved in the incident should make a written statement, giving as many details as possible, including exact words used by the perpetrator. This statement should be undertaken straight away while the incident is fresh in the mind.
Where an injury has been sustained (irrespective of how serious), it must be entered in the accident book and where hospitalisation is not required, the injured party should be advised to consult with a doctor before leaving the premises.
A significant event form on TeamNet should be completed as soon as possible after the incident.
It is Practice policy to press charges against any person who physically or verbally assaults another, damages or steals property.
Where the perpetrator is a member of staff, disciplinary proceedings may also be instigated where deemed appropriate.
The counter fraud and management service and the PCT should also be notified.

Actions following an incident

A meeting to undertake a significant event analysis will be convened as soon as possible which will include the partners, the Practice manager and the staff concerned. Following discussion, further action (if any) will be decided, (e.g. written warning, removal from the Practice list).
Where there are significant mitigating circumstances, (e.g. severe mental problems), these may be taken into account when deciding on any further action.
Details of the incident will be entered in the patient’s medical record or the employee’s personal file unless it has been decided that no further action will be taken.
Any staff involved in a violent incident will be offered counselling and / or medical treatment and encouraged to utilise the Employee Assistance Programme if required.

Appendix 1 - Do’s and Don’ts when facing angry person

If, at any time, a person’s behaviour starts to escalate beyond your comfort zone, disengage.

DO...	Don't..
Recognise your own feelings	Meet anger with anger
Project calmness; move and speak slowly, quietly, and confidently.	Raise your voice, point or stare or communicate in a way that might generate hostility (such as apathy, brush-off, coldness, condescension).
Put yourself in their shoes	Be sensitive or take their acts or words personally
Be prepared to apologise if necessary	Threaten any intervention unless you are prepared to act on it
Assert yourself appropriately	Make them feel trapped or cornered
Be patient - allow people to get things off their chest – when they are calmer and quieter, express your ideas / point of view	Argue or even feel that you have to win the argument
Be an empathetic listener. Encourage the person to talk and listen patiently.	Reject all of a client’s demands from the start.
Focus your attention on the other person to let them know you are interested in what they have to say.	Pose in challenging stances such as standing directly opposite someone, hands on hips, or crossing your arms.
Maintain a relaxed, yet attentive, posture and position yourself at a right angle, rather than directly in front of the other person.	Avoid any physical contact, finger pointing, or long periods of fixed eye contact.
Acknowledge the person’s feelings. Indicate that you can see he (or she) is upset.	Make sudden movements that can be seen as threatening. Notice the tone, volume, and rate of your speech.
Ask for small, specific favours such as asking the person to move to a quieter area.	Challenge, threaten, or dare the individual. Never belittle the person or make him (or her) feel foolish.
Establish ground rules, if unreasonable behaviour persists. Calmly describe the consequences of any violent behaviour.	Criticize or act impatiently toward the agitated individual.
Use delaying tactics that will give the person time to calm down. For example, offer a drink of water—in a disposable cup.	Attempt to bargain with a threatening individual.
Be reassuring and point out choices. Break big problems into smaller, more manageable problems.	Try to make the situation seem less serious than it is.
Accept criticism in a positive way. When a complaint might be true, use statements like, “You’re probably right,” or “It was my fault.” If the criticism seems unwarranted, ask clarifying questions.	Make false statements or promises you cannot keep or try to impart a lot of technical or complicated information when emotions are high.
Ask for their recommendations. Repeat back to them what you feel they are requesting of you.	Take sides or agree with distortions.
Take sides or agree with distortions.	Invade the individual’s personal space. Make sure there is a space of 3-6 feet between you and the hostile/irate person.